How to Treat Depression When Psychiatrists Are Scarce

Psychiatrist Vikram Patel has a radical idea to make mental health counseling available to people in developing countries. Roger Deckker

Mental health doesn’t even rate a mention in most policymakers’ lists of global health priorities. But mental illness and substance abuse disorders rank among the greatest causes of disability worldwide. In poor countries, where there aren’t nearly enough therapists, these conditions cause tremendous suffering and block economic development. Vikram Patel, a psychiatrist at the London School of Hygiene and Tropical Medicine, has a solution: train ordinary people to be coun­selors.

In a rigorous study in Goa, India, Patel found that young women could learn basic psychotherapy skills and go on to help people with depression at least as well as local clinics would have. Now he’s advising the Indian government on incorpor­ating these lay counselors into the national health system. We talked to Patel about why this strategy is necessary for poor countries—and how wealthy countries could benefit too.

Does mental illness get less attention because it doesn’t kill like AIDS and malaria?

PATEL: Mental illness does kill. Worldwide, suicide is one of the primary causes of death in young ­people, and they are the engine of any economy—especially in the develop­ing world. In India, now that maternal mortality is falling, suicide is the leading cause of death in young women. On average, life expectancy for mentally ill people is 15 to 20 years less.

Then why is the focus always on infectious disease?

Before “global health” became a popular term, there was “tropical medicine.” Colonial administrators and soldiers used to end up in the tropics and get sick from things they never saw at home. Most of the ­people who make decisions about global health are in the US and Western Europe. There, the mental health care sys­tem is dominated by highly trained, expensive professionals in big hospitals, who often see patients over long periods of time. This simply can’t be done in rural Africa or India. Who the hell can afford that kind of care? The real innovation is redefining who is a mental health care provider.

Can you train people off the streets, with little education, to be counselors?

We’re training them to do very specific tasks. It’s a bit like training a community midwife: You’re not training her to be an obstetrician; you’re training her to deliver a baby safely and to know when to refer
the mother to a doctor.

The training can be as short as two days or it can be two months, but the classes are the least important part. There’s a much longer period of supervised learning that happens through direct contact with patients. You don’t have much theory. You go directly to the skills you need to actually help people recover.

How do they actually counsel?

Most of our patients are women with depression linked to an unhappy marital relationship. So a counselor would identify the relationship as the reason the patient is feeling withdrawn and not sleeping well. And then they might say, let’s think of things you used to enjoy that can help you feel good again. Maybe that’s getting together with your neighbors, going for a walk in the village in the evening, or playing with your newborn baby. As the patient’s mood improves through repeated sessions, the counselor starts addressing the social problems that made her depressed in the first place.

And your research suggests that this is effective?

It’s not only me saying so. We just completed a systematic review of more than 25 randomized, controlled trials from around the developing world. There’s one clear message: Shar­ing tasks works, and it works across a range of mental health problems.

There must be limits though.

Clearly. We still haven’t figured out, for example, how to train community health workers to diagnose mental illness. That’s a huge bottleneck. To me, that’s the next big step.

Is there a place for this strategy in rich countries too?

According to US statistics, about 60 percent of people with mental health problems received no care at all in the previous year. The normal reaction to that kind of figure is to say we need more psychiatrists. But here’s the thing: The US already has more psychiatrists and spends more money on mental health care than any other country in the world. You don’t need doctors to provide all of the things you’re paying them to provide. You can address many of these problems with behav­ioral interventions that don’t require 10 years of professional training.